Des Moines, Iowa30+ days ago
Provide resources, referrals or coordination to the following as needed: Primary Care providers and specialist, Wellness programs, including tobacco cessation, fitness, nutrition or weight management programs, and exercise facilities or classes, Specialized support groups (i.e. cancer or diabetes support groups, NAMI psychoeducation), School supports, Substance use treatment links and treatment, support recovery with links to support groups, recovery coaches, and 12 step program, Housing services. Collaborates with all members of the multi-disciplinary healthcare team to ensure the delivery of high quality, cost-effective care, as evidenced by coordinated transitions of care; achievement of select quality outcome metrics; appropriate utilization of health management programs and resources, within the structure of a patient-centered medical home.